Making a Drama out of a Crisis

Ahead of the forthcoming #MHPolChat (8:30pm on Monday 14th October 2014) I wanted to re-consider the topic of “Crisis Management” and open up some lines of possible discussion for the chat itself.

One dictionary definition of the term “crisis” is as follows

Noun
1. A time of intense difficulty, trouble or danger
2. A time when a difficult or important decision must be made

Other terms from other dictionaries include “an unstable condition” “a difficult or dangerous time in which a solution is needed – and quickly”

The Oxford English Dictionary takes the word back to its origins “late Middle English (denoting the turning point of a disease); medical Latin, from Greek kris is “decision”, from kronein “decide”.

The definition of “management” in the OED is

Noun

1. The process of dealing with or controlling things or people.

Specifically to medicine and psychiatry it says “the treatment or control of diseases or disorders, or the care of patients who suffer them.”

It is interesting that both of these words appear to have specifically medical origins or connotations.

When put together, I believe that a reasonable definition would be “safely dealing with a situation which is dangerous and difficult.”

In the world of policing “crisis” can take many forms. It could be a natural disaster, a terrorist incident right down through large scale public disorder, a serious crime to dealing with someone whose life is in danger or who is threatening the safety of others.

In the world of medicine I am sure that there are equally many applications for the use of the word “crisis” though, looking at the definition above it would tend to suggest that it is that critical point where medical intervention could save someone.

The intended focus of the forthcoming chat is those situations where the world of policing and medicine combine – or if they aren’t combined – where they SHOULD perhaps combine.

Specifically – dealing with people who appear to be in crisis – whether that be psychosis, suicidal, drug or alcohol induced or illness.

In previous blogs I have talked about the managing of “crisis” within policing within the context of mental health. Over time I have come to the opinion that, actually, a crisis is a crisis and, whilst it is going on, it is the MANAGEMENT of the crisis and the DETERMINATION OF THE CAUSE which is more important than trying to hypothesise remotely and determine WHO IS RESPONSIBLE.

It is my belief that the first two lead ultimately to the third and that there should be expertise from as many experts as possible to help identify what is going on and how to safely manage it.

A recent guest blog from Dr Neill Garrard summed this up beautifully. As an A&E Doctor, Neill was presented with a patient with any number of contradicting symptoms, the cause of the behaviour of this individual could have been down to any number of things which could not be properly determined WHILST the crisis was ongoing. Crucially, Neill and his team had the option of sedation and in a brief moment where the patient was compliant they were able to take this option and then start some proper medical investigation into what was going on.

The fact is that until the patient was calm enough to treat it didn’t matter whether this was a head injury, drug induced psychosis, the onset of some critical illness or simple psychosis. Identifying and treating whichever it turned out to be was crucial to the person’s survival but the over-riding problem was the “crisis” itself. Until that was managed no-one could move forward.

As I said in that blog, now put that same patient, presenting in the same way, in a police station custody suite. Let us be honest, it is a combination of luck and judgement that meant Neill’s patient came to hospital but behaving as violently as he was he could have equally ended up in a police station behaving in exactly the same way.

The options here are limited. Yes – medical advice should be sought and, in these circumstances that should be an ambulance rather than the on call custody health care professional but in the meantime the officers have restraint.

I am quite sure that the staff in Neill’s hospital used restraint and whatever de-escalation skills they have been taught or acquired but they still had the option of rapid tranquilisation.

Police officers do not have this option.

Once officers move to restraint and de-escalation is failing the only tactical option they have is MORE restraint. We know that this is an inherently dangerous, possibly fatal, way of managing people in crisis.

I am not suggesting that officers should have a “tranquilise” option – the very prospect of the police administering medication is Kafka-esque but to me, it demonstrates that the only suitable place for someone behaving like this to be taken is a hospital in case that becomes necessary.

Neither am I advocating a situation where police officers hold someone down whilst they are sedated. If police presence is required and the action is lawful they should be there. What matters is the presence of a clinical professional who can look at the situation and offer an opinion on how to deal with it and then deal with it.

It is the absence of a clinical professional that bothers me about Street Triage. The police are present, a Registered Mental Health Nurse is present but the package does not automatically include a clinical professional who can spot the possible medical causes behind an Acute Behaviour Disturbance.

An ambulance can be summoned to the scene – of course it can – but when you are delivering a bespoke unit with two professionals on board I believe that you are missing the third.

There is an argument for having an Approved Mental Health Professional on board as well.

If these three or four people were sent together, to the same place, at the same time to deal with whatever crisis was occurring AND had the necessary legal powers to make an immediate decision then I believe that it would vastly improve our management of crisis and decrease the risks to the person we have been called to.

Turning up together and assessing the crisis together avoids the hideous situation which currently exists where the person is taken to the wrong place, a cell rather than a hospital or place of safety; where some agencies refuse to come out because of the presence of drink or drugs; where a person can then be assessed hours after the crisis is over and is presenting completely normally.

I have discovered that the term “Crisis Team” when used in the context of mental health sometimes has a very narrow psychiatric definition. “We don’t know that the person is mentally ill because they are drunk.” This is true but the fact is we are still dealing with an acute behavioural disturbance and we actually don’t know what is causing it. It just needs treating.

My main point of debate is that it is nearly impossible to tell exactly what the cause of a “crisis” is whilst it is happening UNLESS you have input, there and then, from all of the professionals it may concern:

Legal / Criminal
Clinical
Mental Health

Only acting together can a crisis be brought under control. At present we are nowhere near being able to safely and consistently get into this position. It matters where you are, who turns up, how the person is presenting and what powers you have (or don’t have.)

For me – a true CRISIS team will consist of members of police, paramedics, RMN and AMHP’s who will all turn up together – deal with the CRISIS in its most holistic definition; collectively and quickly decide which agency’s expertise will have the greatest and safest impact on the situation and effectively MANAGE the crisis to the point where it can be resolved or treated.

Systems Thinking purists may well baulk at this suggestion as the main principle of this approach is to avoid specialism and send the right person first time. This person can then “pull” expertise to a situation or scene from elsewhere if needed.

However, I don’t think my idea falls foul of the Systems approach.

It would be impossible to send the right PERSON to the scene because the fully trained Mental Health / Paramedic / sworn police officer who is also qualified as an AMHP does not exist.

Even the “brightest and the best” would struggle with that many qualifications and roles.

Instead, you are sending 3 or 4 experts who can attend at the same time and pool their minds and training. Yes, it’s a specialist “squad” but crisis is so complex and has so many origins and causes (and indeed solutions) that no one person or agency can deal with it properly alone.

I am not suggesting that every person needs sectioning or hospital admission in the same way as I am not suggesting that every person should be locked in a cell but with all the professionals present at once there is a much better chance of getting that person where they need to be. If they don’t NEED to go anywhere then at least the relevant professional agency can then ensure that there is proper, slower time referral to people within their own agency.

The relevant expertise can be “pulled” to the scene from whichever professional has access to it. It may be police negotiators, a fully equipped ambulance, Section 12 doctors – whatever – the point is that it’s not guesswork any more. Collectively, this small team has assessed the crisis from each speciality and, if it can’t deal with it itself, calls for extra support for the most pressing issue.

Calls involving people in crisis happen across the country many times a day. Situations can suddenly develop in police stations or hospitals and physical and mechanical restraint, in and of itself, is not the answer. This is the reality of the emergency services work every hour, every day, every week, every year.

What should be done when a detainee (under the Mental Health Act or for a criminal offence) suddenly starts violently self harming in a police cell as was illustrated in the Panorama programme a few weeks ago?

Until we recognise that a CRISIS IS A CRISIS and have a team who can descend upon it simultaneously then I do not believe that we will ever get this right and people will continue to suffer the consequences of a disjointed approach. In the very worst examples people have died.

I would welcome your views – please join me on Twitter at 8:30pm on Monday 14th October so that we can discuss this further on #MHPolChat

4 responses to “Making a Drama out of a Crisis”

I have a couple of points about expanding the party, not least the size of the bus we’ll soon need to get this team around. Whilst paramedics certainly are clinical professionals and RMNs clincial of a different kind: neither of them can make medical recommendations that allow AMHPs to Act. At every stage that an AMHP may want to make legal efforst to do anything, they have to be supported by a DR – whether that is attending to a s135(1) warrant or making an application for admission under s2, 3 or 4. So we’ll need a psychiatrist in the truck too to make the AMHP anything more than a social worker with a legal opinion about what might be needed.

As I mentioned on Twitter, we have also heard suggestion of Occupational Therapists being interested in Street Triage, too. The debate for me at least, is getting somewhat out of hand – quite potentially because it was never properly defined what street triage “IS” and what it is meant to “DO”. If, it is about having people present to open up pathways that are not immediately available to the police alone, then the RMN can open up routes into care. If it is about better identifying those clinical issues that may mean someone needs to be signposted after arrest / detention into A&E, then paramedics can do that.

But because we haven’t had it specified what the objective is, it’s impossible to define what the route is to success. It’s a systemic version of “Do Something!” and this being something, we’ll do this.

For my personal part: I want, as a cop, to have options to signpost people into care without coercion unless necessary, I want non-RMN clinical support to help me identify whether I’ve got someone who needs a MHAA or A&E treatment for some other malady – or both. None of that needs an AMHP and it only needs an RMN if the pathways they have access to are denied to paramedics. If we gave the right training to 999 and opened up primary and secondary care pathways into crisis teams or liaison teams, street triage would – in my view – be better done by a police officer and a paramedic. This also has the advantage that they could be used for other things where a police officer and paramedic would be handy too – thereby keeping costs down.

I agree with you in part. Starting with Street Triage – I do believe it is being seen as the answer to a question which has not been properly identified or defined.
In the chat I would like to take it back a step and explore that question. What are we trying to achieve?
As for the personnel on the bus. Yes – I agree that we don’t want to over crowd but I also think it is important that we change this “staggered” approach we have now which allows for non involvement.
Usually police or ambulance attend first and then call the other. Someone then calls the Crisis Team who might call doctors and AMHPs.
All of this takes places and takes hours and what we are actually dealing with is a crisis which needs far more urgent decisions.
I don’t care who goes so long as there is enough collective expertise in the same place at the same time to be able to come to some firm conclusions and quickly.
I am being slightly flippant there. But I do believe that police, paramedic and a mental health professional should be able to attend and make decisions rapidly to defuse or deal with a crisis.
And that if the law doesn’t currently permit this then it’s the law that needs to change.

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